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Leg mass -enough documentation

  1. #1
    Default Leg mass -enough documentation
    Medical Coding Books
    Just want some other views to see if doctor is lacking documentation

    Postoperative diagnosis : Right leg mass

    Operation : Excisional biopsy of right leg mass

    Anesthesia : MAC

    Clinical HISTORY: Patient has a mass on right medial distal leg in need for biopsy

    Procedure? The patient was bought into the operating room, placed on the operating table in supine position. The right distal leg was prepped in a sterile fashion. 10 CC OF 1 % lidocaine with epinephrine were injected for local esthesia> A longitudinal elliptical incision was made to excise the mass with grossly negative margins. Electrocautery was used to dissect through the subcutaneous tissues. Hemostasis was used to achieved with electrocautery. The wound was irrigated with normal saline. The skin was closed with a cobination of 3-0 nylon horizontal mattress ans simple sutures. The patient tolerated the procedure well.

    Would cpt code 27613 be the code or 27618 or do i go into integumentary system, and if so, lack of documentation ?Someone wants told me if its excisional that means they excise the whole mass/tumor/ cyst,so biopsy made not fit ? help

  2. #2
    Your op-report is missing the measurement of the excision. You can code this under the excision of tumor soft tissue as the op-report stated that the tumor was excised with a negative margin. Your code would be right 27618-RT if the excision size is less than 3cm. Hope this helps.
    Last edited by bench; 01-22-2010 at 11:52 AM.

  3. #3
    so it it states negative margins i code into 2000 series /

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